DRG Manager

DRG Manager

Machinify is a leading healthcare intelligence company with expertise across the payment continuum, delivering unmatched value, transparency, and efficiency to health plan clients across the country. Deployed by over 60 health plans, including many of the top 20, and representing more than 160 million lives, Machinify brings together a fully configurable and content-rich, AI-powered platform along with best-in-class expertise. We're constantly reimagining what's possible in our industry, creating disruptively simple, powerfully clear ways to maximize financial outcomes and drive down healthcare costs.

Location : This role is full remote

About the Opportunity

At NewCo, we're constantly reimagining what's possible in our industrycreating disruptively simple, powerfully clear ways to maximize our clients' financial outcomes today and drive down healthcare costs tomorrow. As part of the Complex Payment Solutions team, you will, as the DRG Manager, be responsible for the development and management of our clinical solutions, including MS and APR-DRG validation. This role requires expertise in healthcare payment methodologies and audit and review criteria to target key claims for review and recovery. Key responsibilities include inventory and team management, implementation support, client support, research, and management. This role requires a proactive and strategic thinker with strong leadership and analytical skills to drive the success of our clinical solutions and ensure optimal team performance.

What you'll do

• Enhance and Review Clinical Solutions : Utilize expertise to assist in the enhancement and review of readmissions, place of service, and other clinical solutions.
• Collaborative Development : Work with a multi-disciplinary team of programmers, operations staff, product leaders, and auditors to bring DRG process ideas from creation to implementation.
• Regulatory Monitoring : Assess and adjust written rules by monitoring their effectiveness, keeping up with regulatory updates, and making necessary changes.
• Team Leadership : Lead the DRG team by providing guidance, counsel, and development plans to ensure long-term retention and professional growth of DRG staff.
• Claims Review Management : Oversee the entire process of clinical claims review, understanding various client configurations and workflows.
• Operational Oversight : Manage scheduling, reporting to management, issue resolution, and execution of plans.
• Work Coordination : Assign and prioritize work, set goals, and coordinate daily activities of the team. Provide regular updates and communication through one-on-one and team meetings.
• Performance Monitoring : Monitor individual and team results to ensure timely completion of work in accordance with department standards and medical policy guidelines.
• Analytical Problem-Solving : Demonstrate analytical skills to identify problems and trends, develop solutions, and implement action plans.
• Policy and Process Development : Develop departmental policies, processes, and training standards.
• Support and Evidence : Provide internal and external partners with evidence and references supporting industry standards, auditing guidelines, and review stances.
• Performance Reporting : Provide reports on key performance indicators, including quality scores, workflows, savings, revenue projections, and inventory on a predetermined schedule.
• Solution Development : Collaborate with a multi-disciplinary team to suggest solution development, including operations, product, data analytics, and technology.
• Timeline Management : Set timelines and ensure communication on progress, tracking delivery, and escalating roadblocks or dependencies.
• Program Deployment : Design and deploy effective programs / solutions to identify and correct claims with aberrant results, providing feedback to resolve root causes.
• Research and Special Projects : Assist with research, special projects, and ad hoc claim reviews as needed.
• Other Duties : Perform other duties as assigned.

What Experience You Bring (Role Requirements)

Bachelor's degree (health administration, business, nursing)

Equivalent experience of 5+ years in healthcare billing and coding

Equivalent experience of 3+ years in claims auditing and recovery auditing

Proven experience working within a team, sharing DRG audit process knowledge with sales, marketing, and development teams

Proven knowledge of classification systems, including MSDRG, APR DRG, AP DRG, and outpatient payment systems such as APCs and EAPGs

Demonstrated curiosity and mastery in understanding the root cause of events and behaviors

Strong experience in data utilization and insights

Experience independently structuring and executing complex analyses

Familiarity with Milliman and InterQual guidelines

Expertise in DRG validation

Experience in production and team management

Experience with Readmission reviews

Ability to work efficiently and effectively with minimal supervision

High standards of quality and attention to detail

Deep understanding of Medicare and Commercial coding rules, regulations, and prospective payment systems

Superior knowledge of healthcare coding, billing, and reimbursement

Expert knowledge of clinical criteria documentation requirements

Subject matter expertise in APR-DRG validation, Readmissions, and Place of Service

Experience working with multiple monitors

Proven success in a remote working environment

Proficient in Windows office systems, including the full Microsoft Suite and Teams

Advanced skills in Microsoft Office (Excel, PowerPoint, Word)

Experience with various software applications and collaboration with development teams

Familiarity with multiple encoder / grouper applications

What Success Looks Like

After 3 months

After 1 year

Pay range : $125,000-$140,000

This is an exempt position. The salary range is for Base Salary. Compensation will be determined based on several factors including, but not limited to, skill set, years of experience, and the employee's geographic location.

What's in it for you

What values we'll share with you

At Machinify, we're reimagining a simpler way forward. This begins with our employees. We are innovators who value integrity, teamwork, accuracy, and flexibility. We do the right thing, and we listen to the needs of our clients and their members. As tenured experts with unmatched experience, we champion diverse perspectives that help us to better understand and serve our clients.

Our values come to life through our culture. We embrace flexible working arrangements that allow our employees to bring innovation to life in the way that best suits their productivity. We work cross-functionally, abandoning silos, to bring innovative and accurate solutions to market. We invest in each other through ongoing education and team celebrations, and we give back to our communities through dedicating days for volunteering. Together, Machinify is making healthcare work better for everyone, and we're passionate about a future with better outcomes for all.

We are committed to equal employment opportunity regardless of race, color, ancestry, religion, sex, national origin, sexual orientation, age, citizenship, marital status, disability, gender, gender identity or expression, or veteran status. We